The Veterans Affairs (VA) Cooperative Study #470, a trial of cognitive
behavioral therapy (CBT) and aerobic exercise for Gulf War veterans' illnesses
(GWVI) reported in this issue of THE JOURNAL,1 is
a remarkable achievement. It is the first credible trial of an intervention
for symptomatic Gulf War veterans, and with 1092 individuals randomized at
20 sites, it is one of the largest trials of a psychotherapeutic intervention
ever published. The study used a factorial design to randomize symptomatic
veterans who received usual care, CBT, graded exercise therapy, or both in
combination. The results suggest that CBT leads to a modest reduction in physical
disability (the primary outcome measure), graded exercise has no such effect,
and the combined treatments can lead to improvements in fatigue and cognitive
symptoms but not pain. The modest effects shown in the primary outcome are
difficult to interpret. Should all symptomatic veterans now be offered CBT
or should further research attempt to refine the treatment? If graded exercise
therapy is effective for some symptoms, are there subgroups of patients who
would benefit from it more than from CBT?